December 14, 2022

The most important ophthalmology research updates, delivered directly to you.

In this week's issue

  • According to a multicenter international study, bevacizumab is the most common anti-VEGF agent used in retinopathy of prematurity, while the US had higher rates of retreatment with either laser or reinjection.
  • Rapid progression of macular ganglion cell loss in glaucoma was associated with worse HVF 10-2 performance.
  • Using adaptive optics scanning laser ophthalmoscopy, researchers were able to track subclinical changes in cone receptors for patients with AMD.
  • The APOE-ε4 allele decreases the odds of having glaucoma in patients without systemic hypertension but has the opposite effect in those with hypertension.

That’s a ROP: International trends in ROP management


Our assumptions about retinopathy of prematurity (ROP) may be, well, premature. A multicenter, international study of 23 sites evaluated types and rates of treatment, retreatment, and complications among 1677 eyes of 918 premature infants. Patients in the United States (US) had significantly lower birth weights (665.6g vs. 912.7g) and gestational age (24.5 weeks vs. 26.9 weeks) than non-US patients (p<0.0001). Overall, the most commonly administered anti-VEGF agent was bevacizumab (71.4%), with injections most frequently given 1mm from the limbus (65%). Retreatment was required in 604 (36%) eyes, via laser alone (79.8%), anti-VEGF alone (10.6%), or both (9.6%) and post-injection complications were seen in 0.9% eyes. Of note, retreatment with laser (55% vs 7.2%; p<0.001) or reinjection (8.5% vs. 4.7%; p=0.002) was significantly more common among US patients than non-US patients. These findings highlight significant differences between age and retreatment rates among neonates with ROP around the world, possibly informing future treatment protocols.

Rapid ganglion cell complex thinning is associated with an increased rate of central visual field loss

JAMA Ophthalmology

How fast is too fast for ganglion cell complex thinning in glaucoma? Glaucoma is a progressive, irreversible ophthalmic disease characterized by loss of retinal ganglion cells leading to changes in a patient’s visual field. In the macula, ganglion cell complex (GCC) loss can have a detrimental effect on a patient’s central vision. This cohort study of 202 eyes (48 with glaucoma suspect and 154 with POAG) found that those with rapidly thinning macular GCC’s (>1um/year) showed a higher rate of 10-2 visual field decline (difference, −0.26 dB/y; p = 0.008). The authors suggested that macular GCC thinning should be closely monitored and assist clinical decision making in patients with both glaucoma suspect or POAG.

Can adaptive optics imaging detect changes in cone density among patients with intermediate AMD?

American Journal of Ophthalmology

Can a technology employed frequently in space telescopes help patients with AMD? Adaptive optics scanning laser ophthalmoscopy (AOSLO) is an imaging modality that allows for visualization of the photoreceptors at high resolution. Photoreceptor degeneration has been identified in early to intermediate stages of AMD and is thought to be due to photoreceptor disruption by drusen and subretinal drusen deposits (SDD). This study analyzed AOSLO imaging to determine if there are subclinical changes in cone density for patients with intermediate AMD. 7 patients (10 eyes) with intermediate AMD (5 eyes with SDD, 5 eyes with drusen) were compared to 17 age-matched controls (27 eyes) over approximately 3.5 years. Not surprisingly, cone density was worse in AMD patients. The AMD-SDD group had a greater percentage of abnormal cone density measurements at final follow-up (80% abnormal, compared to 42% at baseline) as compared to the AMD-drusen group (70% abnormal, compared to 31% at baseline). At the end of follow-up, 98.3% of the imaging regions showed decreased cone density in AMD participants as compared to baseline. This study highlights the potential of AOSLO in detecting degenerative changes in AMD with SDD and drusen prior to clinical advancement of the disease.

APOE-ε4 association with glaucoma is context dependent


You've heard that possessing the apolipoprotein E ε4 (APOE-ε4) allele has been linked to Alzheimer's disease. But did you know that it might have an association with glaucoma? Studies so far have yielded mixed results. In this cross-sectional study, data from the Canadian Longitudinal Study on Aging was used to evaluate 24,655 adults of European ancestry, ages 45 to 85 years old. Glaucoma diagnosis, IOP measurements, blood pressure, and blood samples including APOE genotype were obtained. Having an APOE-ε4 allele decreased the odds of having glaucoma only in patients without systemic hypertension (OR = 0.62, 95% CI: 0.46-0.85). Interestingly, patients with hypertension were more likely to have glaucoma if they had an APOE-ε4 allele (OR: 1.47, 95% CI: 1.05-2.08). The authors speculate that APOE-ε4 may exert its effects via the protective effect of microglia, protecting neural cells from the damage of high IOP.


Surgical vs. conservative approach for pediatric CHRRPEs


For these benign tumors, surgery may beat observation. A Combined Hamartoma of the Retina and the Retinal Pigment Epithelium (CHRRPE) is a hamartoma of the neurosensory retina and retinal pigment epithelium with overlying glial cell proliferation that often leads to retinal pucker and distortion, among other complications. Though commonly located in the posterior pole, vision can be affected at different rates depending on tumor location. Indications for surgical treatment include presence of epiretinal membrane causing macular distortion and development of tractional retinal detachment, but there is no consensus on which cases should be treated surgically or conservatively, particularly in pediatric patients. This multicenter, retrospective study evaluated ophthalmic outcomes in children with CHRRPE based on conservative management vs. pars plana vitrectomy (PPV). 62 eyes of 59 patients with an age of 7.7±4.7 years at time of diagnosis were evaluated. 20 patients underwent PPV while 39 patients were followed with observation. Best corrected visual acuity (BCVA) significantly increased from ~20/200 to ~20/90 in the intervention group, with 68.8% of eyes improving. Only 12.9% of eyes in the conservative group had improvement in vision, staying at a vision of ~20/200. The mean central foveal thickness significantly decreased in the intervention group while it increased in eyes followed by observation. This study suggests that vitreoretinal surgery is effective for CHRRPE lesions located in the peripallary and macular region, resulting in visual improvement compared to observation.

Lens Landmarks

No pressure… but we may need to lower the pressure. Prior to the CNTGS, there was no consensus regarding the treatment of normal tension glaucoma – glaucomatous optic nerve damage in the setting of normal range intraocular pressures (IOP). In this 1998 study, patients with normal tension glaucoma were randomized into a treatment cohort (pressure lowered by >30%) and an untreated, control cohort to determine if lowering IOP played a protective role in patients with normal tension glaucoma.

Key Points:
  • At follow-up, mean IOP was significantly lower in the treatment group compared to the control (10.6 mm Hg vs 16.0 mm Hg, P < 0.0001).
  • When using the defined endpoints of optic disc changes or visual field loss, survival analysis showed significantly greater progression of glaucomatous disease in the untreated control (P < 0.0001).
  • Cataracts developed more often in the treatment group, likely due to surgical intervention (38% vs 14%, P = 0.0011).
  • At follow-up, intention-to-treat analysis initially found no difference in visual field survival analysis outcomes between cohorts, but after excluding patients with cataracts (i.e., a treatable problem), they found favorable outcomes for the treatment group (P = 0.0018).
Overall, the CNTGS is a landmark study because it highlights the role of pressure-lowering therapy in preventing disease progression of normal tension glaucoma. Importantly, the visual field benefits were only identified once excluding patients for visual changes secondary to cataract formation. Still, the clinical relevance of the CNTGS showed that treating IOP, even in patients with normal IOP, reduces glaucomatous visual field damage in patients with NTG.

Question of the Week

A 28-year-old man was splashed in the eyes with a chemical solvent while at work. He noted immediate pain and decreased vision despite aggressive irrigation. He has no prior ophthalmic history and does not wear contact lenses or glasses. His right eye is pictured below:
Which one of the following statements concerning this injury is true? 

A. Acid burns cause loss of ground substance and collagen swelling
B. The worst damage from alkali burns occurs immediately
C. Burns at the limbus and burns at the palpebral conjunctiva have a similar prognosis
D. Potential complications include severe uveitis and glaucoma

Keep scrolling for answer or click here

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